Debate on MediShield Life – Keeping Healthcare Cost Manageable

(I delivered this speech on 8 July 2014 during the debate on MediShield Life)

Madam Speaker, I welcome the move to improve protection against large hospital bills and against expensive chronic treatments, as well as to cover those with pre-existing conditions. My colleagues have touched on and will be touching on various aspects of MediShield life. I wish to speak today about keeping healthcare costs manageable.


The Committee reported that in the recent five years, our total healthcare spending has risen close to 10% each year on average. Medical inflation has been rising much faster than inflation in general. The healthcare industry has little incentive in itself to contain costs. If this medical inflation trend continues, it can be worrying as to how much MediShield Life’s premiums will be in future, as well as the cost of smaller medical bills which are not covered by MediShield Life.


The report touched on some areas that the government can look into to contain costs. First, I’d like to understand how we can keep claims reasonable. I’d like to see a robust framework to detect inflated or frivolous treatments by healthcare professionals. Inflated claims can come in the form of prescribing treatments beyond what the patients need or from the over prescription of drugs. How will the government track claims to ensure that even as we strengthen our insurance framework, we will not have inflated claims and unnecessary treatments that will push up healthcare costs, as we have seen that happened in many other countries?


Another way to keep costs manageable is for people to stay healthy. That’s easier said than done. Many in Singapore today are already not healthy, being diagnosed with chronic illnesses. For example, 11.3% of Singaporean adults are diabetic. 1 in 3 people are currently diabetic by age 70. A recent study by NUS Saw Swee Hock School of Public Health forecasted that by 2050, Singapore may have as many as 1 million diabetics, with 1 in 2 being diabetic by age 70. [1] Around 24% of adults in Singapore now have high blood pressure (hypertension). [2] What’s needed will be to prevent those with chronic illnesses from developing complications. Diabetes itself is not scary, but it can lead to kidney failure, or the patient becoming blind or needing amputation. A person with high blood pressure may feel healthy, but the ailment can develop into stroke or a heart attack if the situation is not controlled.


Our lifestyles are increasingly becoming unhealthy. We can put more effort to focus on those that are already diagnosed as unhealthy and invest in preventive care for them. We need to give the best care possible and to monitor the proper taking of medication to prevent complications from developing, which will be life threatening and are very costly to treat. While we currently already have schemes like CHAS and various subsidies for medicines, it is frightening to note that we now have four new cases of kidney failure every day[3] and two cases of limb amputations are performed each day due to diabetic foot complications[4]. We should constantly monitor the schemes to see how they are working and what else can be done if the results are not as good as what we want them to be.


Drugs are another area for cost control. I am also concern about the potential impact that the Trans-Pacific Partnership Agreement (TPP) may have on the cost of drugs. TPP is currently being negotiated between 12 countries which include Singapore. Many negotiating countries have raised concerns about the Intellectual Property (IP) rights chapter in the TPP which reportedly seek a much more stringent level of IP protection than the WTO’s (World Trade Organisation) standards. Fears are that these new rules will strengthen the drug monopoly of big US pharmaceutical companies by altering existing patent laws in their favour[5]. The Medishield Life Review Committee has recommended using generic drugs as far as possible to lower costs. We will need to guard against the TPP drastically changing IP rules that may delay drugs becoming generic.


Next, on electronic health records.  I believe information transparency will allow the government to monitor the performance of healthcare providers and to track if appropriate and cost effective treatments are provided. Readily available comprehensive medical data will allow the government to better manage cost across the entire healthcare sector. This is especially so for the private sector, which the Committee had highlighted concerns about “high professional fees” in the private sector.


Some 10 years ago, the Ministry of Health made it as one of its priorities for the healthcare sector to adopt ICT for health and to set up a common Electronic Medical Record system. Much has been invested in the National Electronic Health Record system (NEHR) and international experts have been brought in to implement the system. I understand that today, a version of the system is used in the public healthcare sector. However, the vast majority of those in the private healthcare sector and those run by VWOs are not yet adopting the system.


For NEHR to help better manage the industry efficiently and effectively, I think it will be necessary to have the private sector and VWO health providers adopt the National Health Record system. We should have all healthcare providers on board the same system. This will let patients have the choice to move to other healthcare providers with full portability of records. The information will allow the government to measure the performances of healthcare providers and if necessary, to even effect changes to payment models, such as to pay for health outcomes rather than just on treatments.[6] I like to know if there are timelines in place for NEHR to be used industry wide.


Healthcare has been a laggard in the exploitation of ICT. As we move to provide wider healthcare coverage for all Singaporeans through MediShield Life, how will NEHR play a role in providing more efficient healthcare?


Also on technology, telehealth or telemedicine offers opportunities to enable the diagnosis, consultation, treatment, education, care management and self-management of patients remotely.  Telehealth can include the home monitoring of chronic diseases, time sensitive assessments in accident and emergency (A&E) departments by medical specialists in another hospital, video conferencing between patients and health providers, and store-and-forward technologies such as for X-Rays and photographs to be captured and transmitted for analysis by doctors later and remotely.


Expanding the use of telehealth has the potential to reduce healthcare costs, increase the level of convenience for patients, and improve patient outcomes over traditional methods. Home monitoring of chronic diseases has been shown to lead to reduced hospitalisations.  A patient in the A&E department can receive care by videoconferencing with a specialist in another hospital and thus may save a transfer to that hospital. Telehealth can provide timely care for stroke patients who may have difficulties travelling to hospitals. [7]


I understand telehealth is currently being piloted in Singapore. We will need to move to an agreed-upon reimbursement model. If doctors cannot be compensated for tele-consultations, they will likely fall back on the traditional mode of getting patients to visit them in their clinics. If patient cannot use Medisave or be covered by insurance for telehealth, they may opt not to have telehealth even if it can be more suitable for them. I’d like to see greater adoption of telehealth through better infrastructure and changes to reimbursement models or regulations that inhibit telehealth.


Finally, the Committee has recommended that the government build up capabilities to evaluate the cost-effectiveness of medical practice, technologies and drugs. I wish to understand what measures have the government put in place to ensure that new practices, technologies and therapies that are cost-effective in achieving a good treatment outcome are covered by Medishield Life? What will be the measures used to define cost effectiveness? What will be the frequency of such evaluation so that good treatment methods can be covered as soon as practical? Will there be a formal institution that will be set up to make these decisions in a transparent manner and to evaluate appeal on decisions? For example in the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) is government-funded and exercises independent and binding decision-making on what the health service needs to offer[8]. Crucial to the Institute’s independence is its transparency in decision-making. The academic research, industry input, patient advocates’ filing, demographic and epidemiologic data that go into the decision-making process are freely available.


In conclusion, MediShield Life is a step in the right direction to ease the worries of Singaporeans on large healthcare bills. I hope the government will examine all ways possible to contain healthcare inflation so that healthcare will be affordable to all.


Madam Speaker, I support the motion.


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